Basic Information
Provider Information | |||||||||
NPI: | 1922328319 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BLACKBURN | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT, CADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 401 E CHESTNUT ST | ||||||||
Address2: | SUITE 610 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402025700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028136600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 401 E CHESTNUT ST | ||||||||
Address2: | SUITE 610 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402025700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5028136600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2010 | ||||||||
LastUpdateDate: | 12/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1106 | KY | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 0824 | KY | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 1106 | 01 | KY | CERTIFIED ALCOHOL AND ADDICTION COUNSELOR | OTHER | 0824 | 01 | KY | LICNESED MARRIAGE AND FAMILY THERAPIST | OTHER |